Treatment

Botulinum toxin is a protein that comes from the bacteria Clostridium botulinum. This is one of the most toxic substances in nature. However, when injected therapeutically in small doses, the toxin is a safe and effective treatment for a variety of medical conditions, including spasticity.

The primary commercial formulations of botulinum toxin available in the United States for these conditions include Botox® (onabotulinumtoxinA), Dysport® (abobotulinumtoxinA), Xeomin® (incobotulinumtoxinA), and Myobloc® (rimabotulinumtoxinB). These formulations differ in potency, thereby requiring different dosages and injection strategies.

Because of the slight risk of bleeding associated with inserting a needle into muscle, please inform your physician of any bleeding disorders or prescribed blood thinning agents (anticoagulants), such as warfarin or aspirin.

What to expectWe administer botulinum toxin injections in an office setting during a visit that is usually no longer than half an hour. The actual injections take only a few minutes. Physicians often use numbing medications (cream or spray) at the site of your injection, to minimize discomfort.

The needles we use for botulinum toxin injections are smaller in size than needles typically used to draw blood. For injection into some muscles, we use an electrical stimulator (EMG) to more precisely identify injection sites. You should experience minimal discomfort or bleeding during the procedure.

Within one to three days, your muscles will begin to relax, significantly relieving your symptoms. This effect usually lasts at least three months, after which time you can be evaluated by the injecting clinician to plan for further treatment, if needed.

Botulinum Toxin Injections for Dystonia and Other Movement Disorders

Dystonia encompasses a range of neurological disorders characterized by involuntary movements. It can affect your neck, eyes, voice, or limbs. Botulinum toxin is the treatment of choice for most of these conditions. Because it is injected in localized muscles, you can avoid the potential systemic side effects of oral medications or surgical complications.

In 2010, the Food and Drug Administration (FDA) approved Botox, a commercial formulation of botulinum toxin, for the treatment of chronic migraine. Doctors affiliated with the Mount Sinai Center for Headache and Pain Medicine are experienced in this treatment.

Intravenous immunoglobulin (IVIG)

Intravenous immunoglobulin (IVIG) can treat a variety of neuromuscular disorders that have an autoimmune basis. It contains healthy antibodies that are purified from the blood of thousands of donors. These healthy antibodies bind the damaging antibodies and clear them from the body. IVIG is administered through the vein. The treatment, which is expensive and may need to be repeated for sustained results, can be managed in the hospital, outpatient infusion center, or at home.

We can treat many conditions with IVIG, including immune neuropathies such as GBS and CIDP, inflammatory myopathies such as polymyositis and dermatomyositis, and myasthenia gravis.

Plasma exchange

Plasma exchange, also known as plasmapheresis, is a process in which we separate blood from the cells using an external filter device (machine). Scientists believe that the therapeutic action of plasma exchange comes from removing damaging antibodies and modulating inflammatory immune complexes. If you have an autoimmune neuromuscular disorder and have been told that you could benefit from IVIG, you may also benefit from plasmapheresis. This test is costly and may need to be repeated on a regular basis for the effects to continue.

The Capsaicin Patch

Capsaicin is the substance in chili peppers that gives you a burning sensation when you eat hot, spicy foods. When applied to certain painful skin conditions, it produces an initial burning sensation, followed by pain relief. A high-concentration capsaicin patch was recently developed for the treatment of certain painful peripheral neuropathies. Mount Sinai Hospital neurologists led research on the high-concentration capsaicin patch and have trained physicians around the world how to use the new treatment. Marketed as Qutenza®, it is now available to treat post-herpetic neuralgia (persistent pain after shingles rash) and other types of painful neuropathies.

To determine whether the capsaicin patch is right for you, your doctor will conduct an initial evaluation at his or her office. If your doctor believes you are a candidate for the patch, he or she will schedule you for a follow-up visit. You do not need any special preparation for this visit.

What to expectAt the clinic, your doctor identifies the area of skin where you experience the most pain. An anesthetic cream (lidocaine) is applied to this area and left on for one hour, after which we wash it off. Your doctor then carefully applies the capsaicin patch and leaves it on for 30 to 60 minutes. You may require more than one patch.

After application, you might feel a burning sensation, like a sun burn. If the discomfort becomes too intense, you will receive oral pain medications. Many patients, however, do not feel increased discomfort during or after the procedure.

After we remove the capsaicin patch, your skin may be slightly red, but this is not dangerous. You may then go home.

Over the next one to two days, you may experience discomfort from the procedure. You can use oral pain medication during this time if you need it. Within days of applying the capsaicin patch, most patients experience significant pain relief in the target area. You should experience pain relief for about three months. We can repeat treatment as necessary.

Acupuncture

Acupuncture can be an effective treatment for chronic pain. This procedure consists of inserting very fine needles in specific points in the body. Sometimes we apply a small amount of electricity to the needles which can make the treatment more effective. Acupuncture has been shown to improve pain by boosting the body’s natural painkillers and by improving blood flow.

Research has shown that acupuncture is useful in treating back and neck pain, headaches, and pain from osteoarthritis. It can also help neuropathic pain, nausea due to chemotherapy, and allergies.